The charge nurse found Alexis Evette Richie alone in a small room at SSM DePaul Health Center, motionless and sprawled facedown on a bean bag chair.

Minutes earlier, the 16-year-old foster child had tried to hit, scratch and bite staff members in the adolescent psychiatric ward. Two aides grabbed her arms and took her down a hall and into a small room called the "quiet room."

They held her facedown in the chair while a nurse injected a sedative into her hip. Alexis continued to struggle and then went limp.

The nurse and the two aides left without checking her pulse or making sure she was breathing.